=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235218959
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ARC OF VIGO COUNTY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/03/2006
-----------------------------------------------------
Last Update Date | 09/06/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 89 CHERRY ST
-----------------------------------------------------
City | TERRE HAUTE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47807-2942
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-232-4112
-----------------------------------------------------
Fax | 812-232-3052
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 89 CHERRY ST
-----------------------------------------------------
City | TERRE HAUTE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47807-2942
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-232-4112
-----------------------------------------------------
Fax | 812-232-3052
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | KIMBERLY GOLDNER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 812-232-4112
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 302F00000X
-----------------------------------------------------
Taxonomy Name | Exclusive Provider Organization
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------